Republicans Now Have 3 Options for Dealing With Health Care

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Badly wounded and humiliated by the latest turn of events, President Trump and Senate Majority Leader Mitch McConnell (R-KY) are blaming Democrats and a few disloyal Republicans who helped block action on the Senate GOP’s star-crossed plan to repeal and replace the Affordable Care Act.

In the aftermath of the devastating announcement late Monday by two conservative Republicans, Sens. Mike Lee of Utah and Jerry Moran of Kansas, that they were joining with Sens. Rand Paul of Kentucky and Susan Collins of Maine in opposing the bill, Trump and McConnell apparently are choosing retribution over statesmanship.

Unable to muster at least 50 of the 52 Senate Republicans to support the legislation – the bare majority they would need under budget reconciliation to pass the bill without a single Democratic vote and Vice President Pence casting the tie-breaking vote --the president and majority leader are vowing to press for action in the coming days to outright repeal the ACA while giving Congress two years in which to concoct a replacement plan.

But already there are indications that this Hail Mary pass approach will fail as well, with moderate Republicans pushing back.

Congressional Republicans and the Trump administration have argued for months that Obamacare, with its soaring premiums and diminished insurance choices, is in a death spiral and that Congress must save Americans from the ill effects of the 2010 legislation. But for all the problems of a program that has provided coverage to more than 20 million people, including expansion of Medicaid, the Congressional Budget Office (CBO) and other individual analysts say that the Obamacare markets have remained relatively stable, while polls show that voters much prefer to hang onto Obamacare than take their chances with the Republican approach.

McConnell, whose reputation as a shrewd deal maker has taken a beating in recent days, insisted Monday night and again today in a floor speech that the Republican-controlled Senate and House already approved a “repeal and delay” bill in early 2015 that President Obama vetoed, and that the two chambers could replicate that vote in the coming days.

“Our Democratic friends have spoken a lot recently about wanting bipartisan solutions,” McConnell said. “This legislation will provide the opportunity for senators of all parties to engage with a fresh start and a new beginning for the American people.”

The president told reporters at the White House today that he wants to “let Obamacare fail” and then have the Democrats and GOP leader to “fix it.” He blamed the Democrats for putting the Republicans in an impossible position to pass comprehensive legislation and insisted that voters would ultimately hold the Democrats responsible. “I’m not going to own it,” he declared.

But in passing the repeal and delay legislation two years ago, the Republicans weren’t shooting with live ammunition: The bill was largely campaign messaging by the GOP, and everyone knew that Obama would prevent it from taking effect. Republicans blithely ignored the warning of the Congressional Budget Office (CBO) that the bill, if enacted, would result in havoc in the individual insurance market, skyrocketing premiums and out of pocket costs, and the loss of coverage for 32 million Americans by 2026.

Trump’s and McConnell’s assertion that Democrats would have little choice but to join forces with the Republicans and negotiate a bipartisan compromise on replacement legislation if Obamacare were given a death sentence effective two years from now is fanciful at best. Senate Minority Leader Chuck Schumer (D-NY) says the Democrats are open for talks now on a wide range of measures to strengthen the existing law and bring down costs, but only if the Republicans abandon their insistence on repealing Obamacare.

“Make no mistake about it, passing repeal without a replacement would be a disaster,” Schumer said in a floor speech today. “Our health care system would implode, millions would lose coverage, coverage for millions more would be diminished, our health care system would be in such a deep hole that repair would be nearly impossible.”

While Republican prospects of making good on a seven-year promise to dismantle the Affordable Care Act appear next to zero at this point, the political situation remains fluid, with the outcome still very much in doubt. Here are three possible scenarios in the coming days and weeks:

Repeal and delay: Like just about everything else connected with the Senate health care deliberations, the decision to go for repeal without replacing Obamacare was made in haste by McConnell and Trump after Lee and Moran jointly announced their opposition to the Better Healthcare Reconciliation Act.

McConnell, 75, has few peers as a legislative strategist, and he is inclined to make split second decisions, as he did in declaring that the Senate wouldn’t consider a replacement for the late Supreme Court justice Antonin Scalia until after the 2016 presidential election, in hopes that a Republican president would make the choice.

Rather than allowing for a day or two of contemplation and consultation on how to proceed, McConnell announced that he intended to hold a vote in the coming days to take up the House-passed version of the Republican health care plan. He would seek passage of an amendment that would strip out many of the new GOP policies but eliminate major portions of Obamacare, including Medicaid expansion, insurance subsidies and fines for individuals and employers who failed to adhere to the law’s mandates.

But McConnell is likely to have as much trouble pushing through this backup approach as winning majority support for the health care reform legislation he almost single-handedly drafted.

Collins, a leading moderate in the party, denounced the approach and promised to vote against it this week or next when it is brought up. “I think [passage] would create great anxiety for individuals who rely on the ACA, I believe it would cause insurance markets to go into turmoil, and I don’t think it is the right way to proceed,” Collins told reporters today.

What’s more, moderate Sens. Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska told reporters that they too would oppose a repeal and delay approach, bringing to three the number of Republicans opposed to McConnell’s tactics and enough to stop them in their tracks.

A bipartisan deal: Feelings about health care reform are running high on both sides of the aisle, and Republican disdain of Democrats for refusing to assist in rewriting the law is matched by Democrats’ contempt for McConnell in totally shutting them out of the backroom deliberations. For those who still believe that Obama and the Democrats passed the ACA without trying to make the bill a bipartisan effort, read this piece in The Atlantic, which shows how McConnell urged Senate to stonewall any cooperation with the Obama administration.

McConnell said recently that if the Republicans couldn’t agree among themselves on legislation to supplant the ACA, they would have no choice but to seek a limited bipartisan deal with the Democrats to buttress the nation's insurance marketplaces. Schumer has repeatedly said that he was open to talks with the Republicans over the future of Obamacare, provided they abandoned their demand for outright repeal of the law and massive cuts in Medicaid for 70 million poor and disabled people,

“We’re ready to sit down right now” and negotiate “if Republicans abandon cuts to Medicaid, abandon huge tax breaks for the wealthy and agree to go through the regular order, through the committees, with hearings, onto the floor, with time for amendments,” Schumer said in a floor speech. “That’s how we perfect legislation here. That’s how it’s been done for nearly 200 years…. Almost inevitably when you try to draft something behind closed doors and not vet it with the public, it becomes a failure – in this case, a disaster.”

Should the two sides eventually get to the bargaining table, the Democrats are likely to press for a handful of other requirements, including the guarantee of a continuous flow of federal cost-sharing subsidies to enable insurers to lower premium costs for low-income consumers, a resumption of reinsurance or “rate corridor” measures that protect the insurance industry from unexpected massive losses, and some steps to rein in the cost of prescription drugs.

Robert Laszewski, a health care consultant, wrote to his clients today, “The fact is that there is no common ground that could garner more than a handful of Republicans willing to save Obamacare. Such an effort would almost certainly now take 60 votes and would require the cooperation of the Republican leadership in both houses willing to let some of their caucus give the Democrats an enormous victory.”

Status Quo and stumbling along: A third possibility is that dysfunction in Congress and a lack of leadership from President Trump could result in a prolonged state of the current status quo. That would present its own problems because the ACA needs serious repair in order to bring premiums and deductibles down to more manageable levels.

The cutoff of some subsidy payments to insurers and the Trump administration’s purposefully vague statements about whether it intends to keep paying others has created the sort of uncertainty that either pushes insurers out of markets they would otherwise serve or forces them to raise premiums to compensate for additional risk.

A continuation of the status quo could help Republicans sell their narrative of a failed Obamacare if it drives more insurers away, but it’s unclear that it would bring lawmakers closer to a viable alternative to the ACA.

Washington Editor and D.C. Bureau Chief Eric Pianin is a veteran journalist who has covered the federal government, congressional budget and tax issues, and national politics. He spent over 25 years at The Washington Post.